CDC issues quarantine order, seeks passengers in drug-resistant TB scare

[vinny]

CDC issues quarantine order, seeks passengers in drug-resistant TB scare
The Centers for Disease Control and Prevention is searching for people who may have been exposed to an airline passenger with a virulent form of tuberculosis.

Dr. Julie Gerberding, head of the CDC, says the person traveled on Air France flight 385 (Atlanta to Paris) on May 12 and Czech Air flight 0104 (Prague to Montreal) on May 24. He entered the United States by car, according to Gerberding.

"We have no suspicion that this patient was highly infectious, in fact the medical evidence would suggest that his potential for transmission would be on the low side, but we know it isn't zero," Gerberding says.

She says a federal quarantine order has been issued and the man is receiving medical treatment. The crew and passengers who sat within two rows of the man should be tested as a precaution, she says.


Gerberding says the man was aware of his diagnosis at the time of the flights, but may not have known that he had a drug-resistant form the disease that is very difficult to treat.

Here's the WHO page devoted to XDR-TB. Here's the list of communicable diseases that are covered by the federal regulations and an overview of the USA's quarantine laws.

http://blogs.usatoday.com/ondeadline/2007/05/cdc_issues_quar.html

[Thornton]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

Text of CDC Health Advisory with link to press conference at end.
The CDC in my opinion is doing good job of providing information to allow specific individuals to determine if they may have been exposed. jt


CDC Health Advisory distributed via the Health Alert Network on May 29, 2007 at 12:40 p.m. EDT.
CDC Health Advisory
Investigation of U.S. Traveler with Extensively Drug Resistant Tuberculosis (XDR TB)
The Centers for Disease Control and Prevention (CDC) is working with a number of international, state, and local partners on an investigation involving a U.S. citizen recently diagnosed with extensively drug-resistant tuberculosis (XDR TB). XDR TB has been recently defined as a subtype of multidrug-resistant tuberculosis (MDR TB) with additional resistance to the two most important second-line antibiotics (i.e., a fluoroquinolone and an injectable agent [amikacin, kanamycin, or capreomycin]) in addition to the two most important first-line drugs (i.e., isoniazid and rifampin).
CDC learned that a patient with XDR TB traveled to Europe via commercial airline (Air France # 385) departing Atlanta on May 12 and arriving in Paris on May 13, 2007, and returned to the United States after taking a commercial flight on May 24 from Prague, Czech Republic to Montreal, Canada (Czech Air # 0104). The patient re-entered the U.S. on May 24 via automobile. Since May 25, the patient has been hospitalized in respiratory isolation and is undergoing additional medical evaluation.
CDC is collaborating with U.S. state and local health departments, international Ministries of Health, the airline industry, and the World Health Organization (WHO) regarding appropriate notification and follow up of passengers and crew potentially at risk for exposure to XDR TB. Each country involved in the investigation is determining the most appropriate guidance for its residents. The following recommendations have been developed for U.S. residents who may have been exposed to this patient.
This patient has radiographic evidence of pulmonary TB, is culture-positive for XDR TB, but is sputum smear negative for acid fast bacilli and is relatively asymptomatic. On the basis of the patient?s clinical and laboratory status, and lack of receiving adequate treatment for XDR TB, this patient was considered potentially infectious at the time of his airline travel, and meets the criteria in the WHO guidelines for initiating an airline contact investigation. http://whqlibdoc.who.int/hq/2006/WHO...06.363_eng.pdf
In accordance with the WHO TB and Airline Travel Guidelines, to ensure appropriate follow-up and care for persons who may have been exposed to XDR TB, CDC is recommending the following for passengers and crew onboard Air France # 385 departing Atlanta on May 12 and arriving in Paris on May 13, and on Czech Air # 0104 departing from Prague and arriving in Montreal on May 24: passengers seated in the same row as the index patient and those seated in the two rows ahead and the two rows behind, as well as the cabin crew members working in the same cabin should be evaluated for TB infection. This includes initial evaluation and testing with follow up 8-10 weeks later for re-evaluation.
As there has never been an airline contact investigation for XDR TB, it is not known if the current recommendations are adequate to determine the possible range and risk of transmission of infection. Because of the serious consequences of XDR TB and anticipated public concern, in addition to the contacts listed above, all U.S. residents and citizens on these flights should be notified and encouraged to seek TB testing and evaluation.
Drug-susceptible (regular) TB and XDR TB are thought to be spread the same way. TB bacilli become aerosolized when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. These bacilli can float in the air for several hours, depending on the environment. Persons who breathe air containing these TB bacilli can become infected.
The risk of acquiring any type of TB appears to depend on several factors, such as extent of disease in the source patient, duration of exposure, and ventilation. Transmission has been documented in association with patients who have lung disease, and bacteria seen or cultured in sputum. Persons who become infected usually have been exposed for several hours (or days) in poorly ventilated or crowded environments. An important way to prevent the spread and transmission is by limiting an infectious person?s contact with other people. Thus, people who have a confirmed diagnosis of TB or XDR TB are placed on treatment and kept isolated until they are no longer infectious.
Persons who believe they may have been exposed to TB or XDR TB can call 1-800 CDC INFO for further information.
Where to go for information about:
Tuberculosis: http://www.cdc.gov/tb/default.htm
XDR TB: http://www.cdc.gov/tb/pubs/tbfactsheets/xdrtb.htm and http://www.cdc.gov/tb/pubs/tbfactsheets/cdcandxdrtb.htm
TB Testing: http://www.cdc.gov/tb/pubs/tbfactsheets/skintesting.htm and http://www.cdc.gov/tb/pubs/tbfactsheets/QFT.htm
Infection Control: http://www.cdc.gov/tb/pubs/tbfactsheets/ichcs.htm and http://www.cdc.gov/tb/pubs/tbfactsheets/rphcs.htm
Tuberculosis and Air Travel:http://whqlibdoc.who.int/hq/2006/WHO...06.363_eng.pdf

Link to press conference from today.

http://www.cdc.gov/od/oc/media/pressrel/2007/r070529.htm

jt

[Gert van der Hoek]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

TB FLIER GETS QUARANTINED

By MIKE STOBBE, AP

May 30, 2007 -- ATLANTA - A man with a rare and dangerous form of tuberculosis ignored doctors' advice and took two trans-Atlantic flights, leading to the first U.S. government-ordered quarantine since 1963, health officials said

Authorities did not identify the man, who's from Georgia, but said he initially entered a medical-isolation facility in New York City, before going to an Atlanta hospital.

He was infected with "extensively drug-resistant" TB, also called XDR-TB, which resists many drugs used for treatment.

Officials at the Centers for Disease Control and Prevention recommended medical exams for cabin crew members on those flights, as well as passengers sitting in the same rows or within two rows.

Airlines were working with health officials to contact those passengers. The infected man flew from Atlanta to Paris on May 12 aboard Air France Flight 385. He returned to North America on May 24 aboard Czech Air Flight 0104 from Prague to Montreal. He then drove into the United States at the Champlain, N.Y., border crossing.

The man had been told by health officials in early May that he had a form of TB and was advised not to travel to Europe.

A CDC official reached the man by phone in Rome and told him not to take commercial flights, but he flew back to North America anyway.

"He was told in no uncertain terms not to take a flight back," said Dr. Martin Cetron, director of the CDC's division of global migration and quarantine.

The man told the Atlanta Constitution he was on his honeymoon with his wife who tested negative for TB. He said the CDC official in Rome told him to turn himself into Italian authorities, so he flew back to Canada to evade the the CDC's no-fly list.

"This is insane to me that I have an armed guard outside my door when I've cooperated with everything other than the whole solitary-confinement-in-Italy thing," he told the paper.

Cetron reached the man once he was back in the United States. At that point, he voluntarily went to the New York hospital, then was flown by the CDC to Atlanta, where he was issued the federal quarantine order. He is not facing prosecution.

http://www.nypost.com/seven/05302007/news/nationalnews/tb_flier_gets_quarantined_nationalnews_mike_stobbe__ap.htm

[Thornton]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

Technical point - the patient is in medical isolation, not quarantine.
Quarantine is when people who may have been exposed but are not sick, are held in isolation to prevent possible spread of illness. Medical isolation is more definite, a person who is sick and probably contagious is isolated from others to prevent spread of disease.
JT

[Gert van der Hoek]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

TB-Exposed Fliers Being Sought by Agencies Globally (Update1)

By John Lauerman

May 30 (Bloomberg) -- A man infected with a dangerous form of tuberculosis who flew on several transatlantic flights has spurred a worldwide search for passengers who shared the flights, sitting within five rows of him.

U.S. health authorities are seeking at least 80 to 90 people from two flights, as well as 27 crew members, to test them for the drug-resistant form of the disease known as XDR-TB, the Centers for Disease Control and Prevention said during a news conference today. Those most at risk of infection sat in the same row as the man, or within the two rows both in front and in back of him, the Atlanta-based agency said.

Those being sought may have sat near seat 51 on Air France flight 385 from Atlanta to Paris on May 12, or seat 12C on flight 0104 from Prague to Montreal on May 24, said Dr. Martin Cetron, The CDC's director of migration. Information on other flights he might have taken is still being pursued.

``This contact investigation is going on in several countries,'' Cetron said today in a telephone conference with reporters. ``We're still reconstructing the seating.''

The World Health organization will track travelers living outside the U.S., Mario Raviglione, director of the Stop TB department at the Geneva-based agency, said in a news conference earlier today.

Screened in March

The XDR-TB infected man, who has not been identified by authorities, was screened in March and found to have the disease, the Fulton County Health Department in Georgia said. Full results of the test, which became available only after he had left on a trip, showed he was infected with XDR-TB, and U.S. health officials ordered him into isolation.

It was the first use of such an order since 1963, when a person was sent into quarantine for a possible smallpox infection. XDR-TB doesn't respond to most available drugs, and patients are sometimes treated by surgically removing infected pieces of the lung officials have said.

The WHO estimates that about 27,000 cases of XDR-TB occur annually, and U.S. cases cost an average of $500,000 each to treat, according to the CDC.

To contact the reporter on this story: John Lauerman in Boston at jlauerman@bloomberg.net .

Last Updated: May 30, 2007 15:43 EDT

http://www.bloomberg.com/apps/news?pid=20601087&sid=aqWFsusklj1w&refer=home

[NurseNalts]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

This is my opionion .... feel free to move this whereever it is most appropriate.

It is very interesting to watch how the CDC and international health agencies handle this. The latest reports state that the unidentified man is held in isolation WITHOUT any charges pending for the extrememly selfish and deliberate exposure of the deadly XDR-TB to so many innocent people!

It is so ironic! Now, if he smoked in the airplane bathroom, he could be punished. But, if he exposes and potentially infects innocent people with a totally drug resistant and highly deadly disease, OH WELL! The man not only knew he had TB, but knew he had XDR-TB before flying back from Praque!

So, what the CDC and other international health agencies are telling us is their systems are slack, they don't have the jurisdiction to even contain 1 XDR-TB patient, and they don't want to interfere with an infected persons "freedoms" to infect others!

Furthermore, what this tells us is that those out there who do have avian influenza and aren't really symptomatic yet, should hop the next plane to the US via Czech Airlines and Montreal, then casually slip thru the border and get some great free health care on us! And don't worry, we won't press any charges!

Why should any country worry about terrorists when we let people with far deadlier weapons through the borders!

This is a very clear demonstration of how terribly unprepared our international air travel systems are to handle such highly infectious diseases. I am an RN who worked frequently with resistant TB patients, we would never allow positive patients to go without their masks. I feel it is nearly attempted murder to knowingly expose others to such a highly deadly disease.

MY HUSBAND was at that SAME Montreal airport, on the SAME day as this man, going thru the SAME US customs. What about my husbands rights, what about our health and the health of our children? (And yes, I know that the chances of him having come in direct contact with the infected man is unlikely, but what about the 100+ others who did?)

What a bunch of crap, what a very slippery slope, and what a very telling scenario of what soon may come ...

maybe this is how the XDR-TB or avian influenza will come to your
town ........

[wdcare]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

http://www.ajc.com/search/content/health/stories/2007/05/29/0530meshtb.html

Atlantan quarantined with deadly TB strain
CDC issues rare isolation order; air passengers warned

By ALISON YOUNG
The Atlanta Journal-Constitution

Published on: 05/30/07

An Atlanta-area man ? infected with a rare, potentially deadly type of tuberculosis ? is under federal quarantine at Grady Memorial Hospital with an armed sheriff's deputy outside his door following his odyssey on international flights, including some to smuggle himself back into the country.


The globe-trotting tale of the man, his fiancee, their wedding and honeymoon abroad ? and conflicting recollections of what he was told about his disease and whether he could travel ? culminated Tuesday with the Centers for Disease Control and Prevention issuing an international health alert.

The CDC is working with airlines to contact passengers who took two transatlantic flights ? a May 12 Air France flight from Atlanta to Paris and a May 24 Czech Air flight from Prague to Montreal ? to alert them that they may have been exposed to extensively drug-resistant tuberculosis.

The disease, also known as XDR TB, is difficult to treat and can cause severe illness and death. Only 49 cases of it have been identified in the United States between 1993 and 2006, according to the CDC.

"I didn't want to put anybody at risk," the Fulton County man, who declined to be identified because of the stigma attached to his diagnosis, said in a telephone interview with The Atlanta Journal-Constitution. "We just wanted to come home and get treatment."

Since January the man, who said he has no symptoms and feels healthy, has met regularly for treatment with Fulton County health officials. He said they and CDC knew he had drug-resistant TB before he left the United States but did not prohibit him from leaving when he told them about his upcoming wedding in Greece.

He questioned why nobody told him to cancel his wedding before he left Atlanta ? and why the CDC waited until he was on his honeymoon in Rome to order him into isolation.

"I'm a very well-educated, successful, intelligent person," he said. "This is insane to me that I have an armed guard outside my door when I've cooperated with everything other than the whole solitary confinement in Italy thing."

At a news conference Tuesday, CDC Director Julie Gerberding announced that the agency had taken the rare action of issuing a federal public health isolation order against the man, which allows the CDC to hold people against their will to protect the public. Gerberding believes the isolation order was last used in 1963 in a case involving a potential smallpox exposure.

"Normally when someone has tuberculosis, we influence them through a covenant of trust," Gerberding said. While saying tests show the man is at extremely low risk of transmitting the disease, Gerberding said the agency is urging passengers who sat in nearby seats and rows during the two long trans-Atlantic flights receive TB tests as a precaution, and that others who traveled aboard the flights be offered the opportunity to be tested if they have concerns.

CDC officials did not release any details about where the man sat on the flights or how many people may have been exposed. They said they would be working with the airlines to contact passengers directly. For now, they said, they're focusing on the trans-Atlantic flights because ? while the risk is very low ? it's where people would have had the most extended period of exposure to him.

"We're balancing both the needs to protect individual freedoms and the responsibility to protect the public," Gerberding said.

"We also want to reassure people who weren't on these flights that the risk of exposure in random air flight is extremely low," she said.

CDC officials note that air travel carries a relatively low risk of infection with TB of any kind.

Because of antibiotics and other measures, the overall TB rate in the United States has been falling for years. Last year, it hit an all-time low of 13,767 cases, or about 4.6 cases per 100,000 Americans. Tuberculosis kills nearly 2 million people each year worldwide.

"What is unusual about this circumstance is that this patient's tuberculosis organism is extremely resistant to the TB drugs that we would normally use to treat infection," Gerberding said.

Gerberding and CDC officials gave few details about what prompted the issuance of a federal isolation order, other than saying the "covenent of trust" had been breached. "In this case the patient had a compelling personal reason for traveling," she said, noting that the man broke no laws in his travels.

The man at the center of the international health incident said his TB ordeal began in January. Because he has felt healthy, the disease was detected by accident, during a chest X-ray for something else. It uncovered a small mass in one lobe of his lung. A sputum test came back negative for TB, but a more sensitive culture test confirmed the diagnosis.

"So they started putting me on the standard four-drug treatment," he said. And they tested his fianc?e and other close contacts for the disease: None of them had it.

But it turned out his TB was resistant to the first-line drugs ? and the second-line drugs. So county officials stopped treatment. The man said he and his private doctor ? with the agreement of government health officials ? made plans for him to undergo cutting-edge treatment with specialists at National Jewish Medical and Research Center in Denver after his honeymoon.

The treatment will involve surgical removal of the mass coupled with drugs to kill the infections. The man said he's been told the course of treatment could take 18 months ? and that the only place that can do it is the Denver hospital.

"The county health department knew I was going over to have a honeymoon. We had a meeting before I left," the man said. He acknowledges that the health department told him they "preferred" that he not to travel. But reluctant to cancel his long-planned wedding, the man said he asked what does "prefer" mean? Does it mean I can't, the man asked.

But even when health officials were quizzed, the TB patient said they never told him he couldn't travel. He told officials he'd be going ahead with his wedding and noted that they didn't tell him to take any precautions, even around close family and friends.

"We headed off to Greece thinking everything's fine," he said. He said he contacted the AJC to make sure his side of the story was heard.

Dr. Steven Katkowsky, director of public health and wellness for Fulton County, said it's his understanding that the man was "advised not to travel."

"I didn't hear that conversation," Katkowsky said, "certainly the recommendation would be that if you have an active infection with tuberculosis, you ought not to be getting on a commercial airliner."

Katkowsky said after that conversation, the department attempted to hand-deliver a medical directive, dated May 11, to the man telling him not to travel, but his home address was vacant and he was not at his place of business.

Katkowsky and CDC officials say they only knew that the man's TB was resistant to many drugs before he left, but that the tests showing he had the most serious form of TB ? XDR TB ? only came back after he was in Europe. The test results came back on May 21, Fulton County officials said.

The man says he and his bride were in Rome on their honeymoon when they got a message to call the CDC. The CDC official said that they needed to cancel their trip and return home and that the CDC would call the next day with travel information.

The patient says he and his wife canceled plans to move on to Florence the next day as they awaited the CDC's instructions.

The next day, instead of giving the couple travel arrangements, the man said a CDC staff member told him he'd need to turn himself into Italian health authorities the next morning and agree to go into isolation and treatment in that country for an indefinite period of time.

"I thought to myself: 'You're nuts.' I wasn't going to do that. They told me I had been put on the no-fly list and my passport was flagged," the man said.

The man said the CDC told him he could not fly aboard a commercial airliner with his disease. "We asked about the CDC jet and they said no, there wasn't funding in the budget to use the jet," he said.

Dr. Martin Cetron, director of the CDC's division of global migration and quarantine, did not respond to repeated requests for an interview. Cetron told The Associated Press: "He was told in no uncertain terms not to take a flight back."

CDC spokesman Tom Skinner said the agency was considering sending the CDC's jet to Italy to retrieve the man ? when he disappeared and didn't meet Italian health authorities.

"We're sitting in a hotel room in Italy and we're looking at each other and we're on our honeymoon and the authorities are coming in hours," the man recalled. They made the decision to run.

To evade the no-fly list, which they assumed only involved jets bound for the United States, the man and wife flew into Canada and drove a car into the U.S. At every check of their passports, he said they feared being caught, but weren't.

He said he called the CDC when he was back in the U.S. and agreed to the agency's request to drive first to a TB isolation hospital in New York City for some tests. That's where federal officials served him with the federal isolation order, he said. The agency ultimately flew him Monday on the CDC jet to Atlanta.

The patient is now in an isolation ward at Grady Memorial Hospital, said spokeswoman Denise Simpson.

The man said he wants people to understand he sneaked back into the United States because he feared for his life. An unsuccessful treatment in Italy would have doomed him, he said, because he said they lacked the expertise.

CDC officials are investigating how the man became infected with XDR TB. He said the agency thinks he may have gotten it while he was traveling in Asia doing fund-raising work for hospitals.

To reach reporter Alison Young, call 404-526-7372.

Staff write Kevin Duffy contributed to this article.

Diagram of where he went is at link above.

[AlaskaDenise]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

...........It is very interesting to watch how the CDC and international health agencies handle this. ............So, what the CDC and other international health agencies are telling us is their systems are slack, they don't have the jurisdiction to even contain 1 XDR-TB patient, and they don't want to interfere with an infected persons "freedoms" to infect others!

Furthermore, what this tells us is that those out there who do have avian influenza ...........This is a very clear demonstration of how terribly unprepared our international air travel systems are to handle such highly infectious diseases.

.............What a bunch of crap, what a very slippery slope, and what a very telling scenario of what soon may come ...

maybe this is how the XDR-TB or avian influenza will come to your
town ........

This is a good dry run for our pandemic fighters, isn't it?

Nobody is asking..........where did the Atlanta case catch the disease? Is anyone tracking HIS contacts?

.

[Thornton]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

Hard not to comment. Quote from the 615pm post above.

CDC officials are investigating how the man became infected with XDR TB. He said the agency thinks he may have gotten it while he was traveling in Asia doing fund-raising work for hospitals.

jt

[NurseNalts]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

To Thornton, Please comment on the XDR-TB traveler! Is it hard not to comment on the way he may have acquired the TB or the escapade which played out in his return to the States?

I would love to hear some insight from an experienced medical professional on how/why the CDC and local health departments messed up, how CDC can more swiftly reach international cooperation to contain infected persons and your insight on what we need to do with our borders and international travel to help prevent other dramatic scenarios.

We all know about patients rights, but clearly, an "understanding of trust" was not the most effective plan of containment in this case! Thank you for your response.

[chicken little]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

CDC's Gerbending's comment that "Normally when someone has TB,we influence them through a covenant of trust",leaves me quite gob-smacked.What is normal nowadays? When one individual's non -compliance can now possibly cause a global pandemic(an extreme but real scenario),should we not be thinking less about the rights of the "offender" and more about the rights of society as a whole?
This is a "head scratching" issue for me because I'm not a communist and I appreciate Western freedoms but this pandemic issue,among others,has me thinking about whether or not we are as smart as we think we are.
We may lose it all for fear of litigation.Am I wrong?

[Thornton]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

Responding to Nurse Nalt Post #10 and some of the events of the past 2 days. My comments (prudently) are about the information reported and not the specific individual. I have to write a lengthy section on background of what is expected in order to show what is unusual.

First - the management of TB mdr TB and xdr TB. The press is reporting that the person had a nodule discovered incidentally on a CXR taken to evaluate a sports injury. Eventually (date not known) they biopsied the nodule. Typically the lab is ordered to microscopically examine the tissue and somewhere we presume they did what is called a AFB (Acid fast bacillus)stain. The AFB we presumed showed TB and then they should have done 3things. Immediately place him on drugs for treatment, and notify the health department and obtain more tissue to grow in culture and verify sensitivities.
I saw on CNN Sanjay Gupta report last night that the health department was notified April 23 of a case of TB. (Lesion identified in January, health dept notified in April). We assume that notification occurs simultaneous with treatment thus no treatment for ACTIVE disease for several months. I say ACTIVE disease because the report is of a lesion visible on CXR, and subsequent growth in culture.

When we are treating active TB cases within an institution, the patient stays in negative airflow isolation until we obtain good sputum samples that are negative on AFB stains on 3 separate days. Since the reports are that there was no coughing, no sputum then no infectious material. The assumption is the person is placed on an effective 4 drug regimen for 6 months for drug sensitive TB to control any further growth of the infection.

See the CDC guidelines for TB treatment.

http://www.cdc.gov/tb/pubs/PDA_TBGuidelines/default.htm

The 4 first line drugs isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide (PZA) are not benign. For example, just for converting a skin test that was negative to positive leads to the recommendation to prophylaxis with INH for 9 months.
In my forensic institution on any given day we have 10 to 20% of patients on prophylactic therapy. INH is toxic to the liver and causes peripheral neuropathy. All patients are supplemented with Vitamin B6 to prevent the peripheral neuropathy. Liver function tests are monitored and patients are prohibited from drinking alcohol (advised).
INH can cause significant neuropsychiatric side effects such as hypomania or mania.

I am curious that they have not said anything about the drug regimen he was on since April 23 when the case was reported.

I believe the reports that the degree of infectiousness is low because he is not coughing but is not zero because he has lung tissue with growing organisms. It is possible to determine a snapshot of infectiousness by filtering (HEPA microfilters) all the air that is pulled out of his room and searching the filter for detectable organism. This is only of academic interest because it is just a snapshot and cannot tell you the degree of infectiousness the day before of the day after and does not impact treatment.

I watched part of the news conference on Thursday afternoon with Dr Huitt at the Jewish Hospital She expressed much optimism and cited the excellent general health of the patient. Yes, that is true, most patients with active TB also have other significant medical illnesses and that is partly what allows the TB to grow (we believe). Another way of looking at this is the fact that a young person in excellent health develops cavitary lung lesions is cause for concern with drug sensitive TB. The CDC determined that since it is XDR TB that is was cause for alarm.

[B]Next, what about the reported discrepancies in communications among health authorities and the patients? press accounts? I view this as a clash of cultures and values. Again I will say what has crystallized for me from this is that all epidemics are behavioral.[/B]

The general public most likely believes that the CDC was in control of this case. The best I can tell it was never in control until it assumed control on May 24. The reports I have is that the person was under private care and even the local health department was not informed until April 23. I assume more details on the care provided by the private practitioners will be forthcoming and scrutinized. Last night on the same CNN report I saw briefly portions of an interview with the Fulton County health director. Once notified of the TB case they had jurisdiction of tracking. Here is where a cultural clash manifests. When a doctor (or public health official) provides ?strong advice? or ?strong recommendations? we are of the mind that it is an order and violation of the order falls on the patient. In my forensic environment, I deal with judges who view medically offered ?strong recommendations or advice? as options. The judge issues an order and expects compliance. The attorney sees the orders as arguable points. Just my observation from my experience in working in a public health / criminal justice environment. (Most of my patients are my patients because they will not even accept an order from an armed law enforcement officer without physical resistance.) What I would emphasize as the lessoned re-learned from this episode is that health care providers must have a full appreciation for the multiple value systems they encounter and adjust their communications accordingly. The simplest way to ensure good communications is to ask for the other person to repeat back in their own words what they are to do. (Note, this is very different than asking them to repeat back what you said).

The clash of values has to do with life, liberty and the pursuit of happiness (acquire wealth). Although many of us believe our right to life trumps any other right, that is not the case with the operations of US law at present. We have a long list of innocent deaths for the rights of others to bear arms, maintain liberty and privacy (eg Virginia Tech, domestic violence victims, placing dangerous prison inmates into mental health treatment facilities, etc). The balancing of these rights require much more thought and precision than is evident in the public media.

Finally we get into the tin hat arena of coincidence. I would think that if the Director of the CDC knew that the person placed on a world wide watch list was a family member of a CDC employee that this may have been handled less in the public eye. If the Director knew at the time of the May 29 press conference, I would think that in the interest of credibility that information would have been disclosed at the time of the alert. So we now have to ask who knew what and when? I am certain more information will come in the days and weeks ahead.

So back to the mathematics of coincidence (chance). For a typical science project we accept a 5% probability of chance as evidence of disproving the null hypothesis (ie reject change) and support of the hypothesis (not chance). For a traveler to Asia to convert a skin test to show infection with TB is not unusual. For a young healthy person to develop cavitary lesions is very unusual. In the CDC material there is indication the XDR TB may be more pathogenic. However, the acquisition of XDR TB by an American traveler is newsworthy. If we were to profile the vulnerability of an American to acquire XDR TB we would look for NGO workers in South Africa. So we have 3 unusual demographics: 1) healthy vs co morbid illness; 2) fund raiser vs direct care worker; 3) Asia vs Africa. Then we have the unusual management ? the presence of active TB I young healthy male should have caused focused attention and multiple providers. Then we have unusual behavior ? travel overseas, multiple foreign trips and a covert border crossing. Finally the incomprehensible personal relationship to a CDC employee who happens to research TB. I cannot say what the comprehensible story will be, but for most people any story is more believable than coincidence.

Then it keeps getting weird. This long planned wedding - the couple did not have the proper paperwork for an official wedding. http://test.denverpost.com/ci_6037621

So back to the request by NursNalt on what can the CDC do to improve our protection?
My opinion is :
1. It is not solely a CDC problem US citizens will be more safe from dangerous illnesses when the entire world is safe from dangerous illness. Americans and other members of the developed world need to do more to assist in the elimination of TB, malaria, measles, poor water and famine.
2. The CDC should aggressively assist in getting the full truth out or at least stating they are nor permitted to disclose the truth.
3. In my personal opinion this instance is not simply a case of a system breakdown. The system rules were distorted somewhere by someone. This comes down to the coincidence vs not coincidence issue. In my personal opinion the story as it is is weal for coincidence. If the story?s facts hold up then one is not able to disprove coincidence. If the story facts continue to evolve unexpectedly ( eg the non-wedding wedding) then the coincidence explanation gets weaker and weaker.

(My disclosure - As a third year medical student I converted my TB test. I could have acquired it from 2 medicine ward patients diagnosed with TB at autopsy or one psychiatric patient court ordered into isolation for refusal to comply with treatment for active TB. I took INH for one year along with Vitamin B6. My repeat chest xrays continue to be negative for over 20 years. I have had 8 years of public health responsibility for TB screening and management in a state correctional facility and a state mental health treatment facility.)
JT

[sharon sanders]

CDC Update

Media Update

<table border="0" cellpadding="0" cellspacing="0" width="100%"> <tbody><tr> <td align="left" valign="top" width="50%">FOR IMMEDIATE RELEASE
Saturday, June 2, 2007
</td> <td align="left" valign="top" width="50%">Contact: This update is being provided since CDC?s Media Relations Office is not available to take media calls on weekends.
</td> </tr> </tbody></table> CDC Media Update: XDR TB Public Health Investigation

The Centers for Disease Control and Prevention provides the following update regarding its investigation and public health actions related to a patient with extensively drug-resistant tuberculosis (XDR TB). CDC is recommending that passengers and crew on two trans- Atlantic flights taken by the patient be notified of potential exposure to tuberculosis and evaluated for TB. On May 12, the patient flew from Atlanta, Georgia, to Paris, Francis on Air France flight #385/Delta Airlines flight #8517. On May 24, the patient flew from Prague, Czech Republic, to Montreal, Canada, on Czech Air flight #0104. There were 292 U.S. residents or citizens on the Air France/Delta flight and two on the Czech Air Flight (the patient and his wife).
Update: Notification of Passengers

As of 12 p.m. on June 2, 2007, there were 292 U.S. residents or citizens identified as having traveled on the Air France flight. Earlier reports identified 310 U.S. citizens or residents on the flight, but that number was updated to 292 based on elimination of duplicate names.
As of 3 p.m. on Saturday, June 2, 2007, CDC staff has talked directly with 160 of the 292 U.S. residents or citizens on board the Air France/Delta flight (i.e., 55 percent), and are actively pursuing contact with the other 132. The 160 contacts range from talking directly to passengers, family members, or relatives (in some cases the U.S. passengers are living in or still visiting other countries). All 26 U.S. passengers in five highest priority rows (i.e. the row the passenger was in and the two rows in front and behind) have been contacted. Six of those are currently outside of the United States and family members or relatives were contacted.
Update: Denver Health Authority Public Health Department Issues Isolation Order

The Denver Health Authority Public Health Department has issued an order that requires that the patient be detained at National Jewish Medical and Research Center until further laboratory tests indicate that he is no longer contagious. The patient is currently considered infectious based on three respiratory tract specimens that were reported culture positive for extensively drug-resistant tuberculosis (XDRTB).
Since the order by local public health authorities puts in place measures that are sufficient to protect the public?s health, the federal isolation order that has been used to ensure the patient remains in medical isolation is no longer in place. CDC will continue to provide input and consultation to appropriate authorities on the diagnosis, management and methods for preventing the spread of communicable disease.
Update: CDC activities

CDC will be undertaking a number of reviews related to this XDR TB case. One aspect of this review will be looking at how the CDC employee who is related (father-in-law) to the patient was involved in this matter.
Information for Media Audiences

Many recent media stories have conveyed information or impressions regarding tuberculosis that are inaccurate, including information about how the disease is transmitted, how quickly people may become infected or show symptoms, and the contagiousness of the disease.
There are some other important characteristics of tuberculosis that need to be conveyed:

• Only a person with active TB disease can spread TB bacteria to others.
• Persons who have spent prolonged time with someone with active TB disease should get tested for TB infection. It usually takes prolonged exposure to someone with active TB disease for someone to become infected.
• After exposure, it usually takes 8 to 10 weeks before the TB test would show if someone had become infected.
• A person with a positive test for TB infection (i.e., latent TB infection) is not sick, and cannot spread TB germs to others. However, some of these persons can go on to develop TB disease, especially if their immune system is weak, for example, HIVinfected persons, persons with diabetes, or persons undergoing treatment for certain forms of cancer.

Frequently asked question:
What should a person do if they were on the Air France flight #385 / Delta flight 8517 on May 12 with the XDR TB patient?

They need to go to their doctor or local health department and request a TB evaluation, as well as contact their State TB Control Office. They should be evaluated for signs and symptoms of TB disease, and get a TB skin test or the QuantiFERON?TB Gold blood test (QFT-G) to test for TB infection.
It can take 8 to 10 weeks after infection for a person?s immune system to react to the TB skin test or QFT-G. It is important to get a TB test as soon as possible because people may already have latent TB infection, but are unaware since there are no signs and symptoms. The first test is needed to determine whether a person already had latent TB infection before this recent exposure. A person with latent TB is not infectious.
If a person?s first test is negative, they will still need to get a second TB test 8 to 10 weeks following the flight date (i.e., the time of their last possible exposure to the patient) to determine if they may have been infected by the XDR TB patient. If the first test is positive, their doctor or nurse may do other tests to see if treatment is needed.
For additional information call 1- 800-CDC-INFO (1-800-232-4636).
For more information about XDR TB, please visit http://www.cdc.gov/tb/xdrtb/.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

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[Thornton]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

Below is a story contrasting the 2 cases of XDR-TB in US and their treatment. Included in the link is a video report of the ACLU suing the Maricopa County Jail for the extreme isolation measures for its Robert Daniels. Finally an incidental story on a false smallpox scare in North Carolina. All of these lead to my moniker ? "all epidemics are behavioral."
I use that to draw attention to the social cohesion necessary to control and prevent disease. - JT

2 cases stirring TB fears

http://www.azcentral.com/arizonarepublic/news/articles/0601tbscare0601.html

Health officials, U.S. public question national readiness
Robert Anglen
The Arizona Republic
Jun. 1, 2007 12:00 AM
In Phoenix, a man sits in a hospital isolation unit, terrified he is about to die.

In Denver, the first person in the United States to face a federal quarantine order since 1963 might need portions of his lungs removed.

The two men have one thing in common: a virulent strain of drug-resistant tuberculosis that has sent waves of alarm across the country about the risk of contracting the disease and the government's ability to stop it.

The cases have heightened worries among health officials, left airline passengers voicing concerns over international travel and sparked worldwide news coverage. Tuberculosis was thought to be a plague of the past here, a threat only in developing countries.

The cases of Robert Daniels of Phoenix and Andrew Speaker of Atlanta are shifting that view.

But the real threat of extensively drug-resistant (XDR) TB in the United States is not an immediate pandemic.

What worries health officials more is the emergence of a disease that over the next few decades could render drugs useless and push the country back into the bitter past, when isolation, containment and quarantine were the only ways to thwart its spread.

"If TB is less under control . . . it is much more likely for (extremely drug-resistant) strains to develop," said Bob England, director of Maricopa County Department of Public Health. "When that becomes the norm, it will be like going back to the days when we didn't have drugs."

In the short term, some people are uneasy, and others mad.

In Phoenix, public-health officialssay they were outraged when they say Daniels, 27, violated rules of voluntary quarantine by not taking his medicine and going to local stores without wearing a mask. Daniels, who denies not wearing a mask, was ordered by a judge into an isolated jail ward at the Maricopa Medical Center, where he has been for 10 months.

Elsewhere, airline travelers are angry that Speaker, a 31-year-old personal-injury lawyer from Atlanta, flew to Canada and then drove into the United States knowing he was infected with virulent TB. He had ignored warnings from doctors not to return to the U.S. from his European honeymoon.
When the Centers for Disease Control and Prevention discovered he was back in the country, it ordered Speaker quarantined, transported him to a hospital in Denver and began searching for passengers who were on his flights.
So far, public health authorities have not identified any additional victims, and there is a very good chance that nobody else was infected. The reassurances haven't erased the worries, especially among travelers.

"It definitely concerns me," said Christine Rice, a 23-year-old sales consultant with the Christmas Light Company in Phoenix who travels as part of her job. "It's not something I would have thought about before. But now . . . I'm not even sure how you could beef up security to stop it."

According to the CDC, there have only been 49 cases of the XDR reported in the United States since 1993, not including the two newest cases. Of those, 17 were reported between 2000 and 2006.

Despite the low numbers, the CDC in October issued a health bulletin that described XDR-TB as a potentially untreatable future epidemic. The bulletin said patients in the United States with XDR were 64 percent more likely to die during treatment than patients who contracted multi-drug resistant strains.

In Arizona, about 300 new cases of tuberculosis are reported each year. In Maricopa County, the number is about 170. Only about one person a year in the state is forced into court-ordered isolation or placed in a specialized ward away from the public.

Ken Komatsu, state epidemiologist for the Arizona Department of Health Services, said the vast majority of patients are concerned that they might expose others and voluntarily take precautions to limit exposure.
He said drug-resistant forms of TB, while rare, are becoming more common, especially in developing countries, where treatments are incomplete.
"Inadequate treatment leads to the disease," he said, explaining that the drug mutates when treatment isn't followed up or the right medicines aren't given.

Komatsu said Russia is an area of risk because of its failing infrastructure. He said medicines once used to successfully treat the disease in Russia now are being given without proper follow-up, allowing the disease to spread.
Daniels, the Phoenix patient, said that he contracted the disease in Russia, where he is also a citizen. He says he moved from Russia to Arizona in 2006 to find work and became severely ill. He was placed in a county sanitarium for indigent TB patients.

In the Speaker case, passengers who sat next to the Atlanta attorney on several flights, said they had no idea their fellow traveler was infected and expressed outrage that he may have put their health at risk.

"It's still very scary," Laney Wiggins, 21, one of more than two dozen University of South Carolina-Aiken students who are getting skin tests for TB, told the Associated Press. "That is an outrageous number of people that he was very reckless with their health. It's not fair. It's selfish."
Health experts said the likelihood of a transmission was low, partly because Speaker has a small amount of TB bacteria. England said tuberculosis is slow-spreading and not nearly as infectious as even the flu virus.

That hasn't stopped callers from contacting airlines and questioning them about the safety of flying. "There certainly has been an increase in calls," said Phil Gee, a spokesman for U.S. Airways in Phoenix.

He said most callers want assurances that the airline has procedures in place to deal with a communicable disease. Gee said the airline will almost always turn decisions over to the CDC or other health officials when a situation arises, as it did two months ago when a passenger in North Carolina falsely claimed to have smallpox.

"We sequestered the plane for a couple of hours," he said. "We had on the air conditioner. We brought in food and water (for passengers)." In that case, the passenger was suffering from mental illness. "It is occasionally one of those issues that arises," he said.

Reach the reporter at robert .anglen@arizonarepublic.com or (602) 444-8694.

[sharon sanders]

Re: CDC issues quarantine order, seeks passengers in drug-resistant TB scare

WASHINGTON, June 14 (Reuters) - The U.S. man with a dangerous form of tuberculosis who triggered an international health scare last month will have surgery to treat his infection, hospital officials said on Thursday. "Andrew Speaker is an excellent candidate for surgery," said Dr. Charles Daley, head of the hospital's infectious disease division. "The infected area of his lung is relatively small and well contained. He is also young and otherwise healthy." Andrew Speaker, 31, will have a tennis-ball-sized piece of his lung removed to get rid of diseased tissue and most of the remaining TB bacteria, said officials at National Jewish Medical Center in Denver, where Speaker is isolated. The hospital said other patients with multi-drug resistant tuberculosis who have had similar procedures became culture-negative and were able to go home a month after surgery. Culture-negative means no bacteria can be found in a patient's sputum, even after growing it in the lab. The Atlanta lawyer will have the surgery next month at a University of Colorado hospital and continue to take antibiotics. He has extensively drug-resistant tuberculosis, which resists virtually all of the usual antibiotics used to treat the disease. Patients must take a cocktail of strong antibiotics for months or even years to cure their infections. Hospital officials have estimated that Speaker's treatment will cost $250,000 or more. Speaker made headlines in May when he evaded authorities trying to stop him. He flew to his wedding in Greece, honeymooned in Rome and went through the Czech Republic and Canada before re-entering the United States. The U.S. Centers for Disease Control and Prevention ordered Speaker isolated, the first time such a federal isolation order had been issued in 44 years. Although Speaker was never considered highly infectious, his type of TB is so dangerous that officials do not want patients to travel because the risks are so great to others. The CDC and health authorities in Europe tracked down more than 100 passengers and crew on two flights who sat near Speaker to urge them to get tested for TB. Speaker's voyage also prompted investigations by Congress into how the CDC and border authorities handled the matter. The World Health Organization said the CDC was slow in notifying other health departments about Speaker's condition, and the newlywed couple crossed the border from Canada despite an alert that should have stopped them. The CDC is also investigating the role of Speaker's father-in-law, a veteran TB researcher at the agency. The CDC has denied Speaker's infection originated there.

http://www.alertnet.org/thenews/newsdesk/N14172367.htm